Case-Control Pilot Study of Soft Contact Lens Wearers With

Corneal Infiltrative Events and Healthy Controls

PURPOSE. The purpose of this study was to assess risk factors associated with soft contact lens
(SCL)-related corneal infiltrative events (CIEs).
METHODS. This was a single-visit, case-control study conducted at five academic centers in
North America. Cases were defined as current SCL wearers with a symptomatic CIE. For
each case, three age- and sex-matched controls were enrolled. Subjects completed the
Contact Lens Risk Survey (CLRS), a standardized scripted medical interview, supplied a
recent health history, and underwent an ocular examination. Microbial culturing of the
ocular surface, SCL, and lens storage case was conducted for all cases and one of the three
matched controls. Univariate and multivariate logistic regression modeling were used to
assess the risk of developing a CIE.
RESULTS. Thirty cases and 90 controls 13 to 31 years of age completed the study. Corneal
infiltrative event diagnosis included contact lens–associated red eye, infiltrative keratitis, and
contact lens peripheral ulcer. Subjects with symptomatic CIEs were more likely to harbor
substantial levels of gram-negative bioburden on the ocular surface and contact lens.
Significant risk factors for developing a CIE were overnight wear of SCLs, use of multipurpose
solution, rinsing SCLs with water, lens storage case older than 6 months, previous ‘‘red eye’’
event, use of ocular drops in the past week, and illness during the past week.
CONCLUSIONS. This pilot study demonstrated feasibility of enrolling a representative pool
of SCL wearers with an untreated, symptomatic CIE and assessing CIE risk factors by using
standardized methods. A larger sample size is needed to determine relationships between
patient-reported behaviors and exposures, microbial bioburden, and CIE development.
Keywords: adverse events, contact lenses, corneal infiltrative events, microbial culturing

Arecent report from the US Centers for Disease Control and Prevention (CDC) called
to light the substantial burden associated with contact lens–related complications.1 The
CDC report estimated that contact lens–related keratitis results in nearly 1 million doctor
visits each year and carries an associated cost of $175 million.1 This estimate does not
include the additional ‘‘costs’’ to the patient such as pain or discomfort, missed school or
work, and potential for permanent loss of vision.
Approximately 37 million people in the United States currently wear contact
lenses and, due to the increasing prevalence of myopia, more and younger patients
are expected to begin wearing contact lenses to aid in its management.2,3 Research
has demonstrated that adult and pediatric patients can safely wear soft contact lenses
(SCLs) within controlled trials, with relatively low rates of complications, especially for daily
lens wear.4,5 However, as with most medical devices, when contact lenses are used by the
general population outside of controlled trials, the rate and types of complications
increase.1,6–8 The increased risk of complica- tions is likely caused by poor wear and care
behaviors, but the cause and effect relationships are not entirely clear, especially to patients.9–
12
The Contact Lens Assessment in Youth (CLAY) group developed the Contact Lens
Risk Survey (CLRS) to thoroughly and systematically evaluate patient-reported behaviors and
exposures associated with contact lens wear. The CLAY Observations of Risks Associated with
Contact Lenses (ORACL) study was designed to pilot methods for conducting a
multicenter clinical study to explore relationships between patient-reported behaviors and
exposures, microbial bioburden, and risk factors for developing contact lens–related
corneal infiltrative events (CIEs).

METHODS
Study Procedures
The ORACL study was a multicenter, single-visit, case-control pilot study conducted
at five academic centers in North America (see Supplementary Appendix for sites). The
study followed the tenets of the Declaration of Helsinki and was approved by each site’s
Institutional Review Board prior to recruitment. Current SCL wearers (defined as having
worn SCLs in the last week) between 12 and 33 years of age were recruited. Case subjects
were patients presenting with untreated, symptomatic CIEs. Control subjects were sex- and
age-matched (62 years), and three controls were enrolled for each CIE case. Control subjects
were excluded if they had had an eye examination in the 3 months prior to the study visit in
order to minimize the effects of recent patient education or change in SCL brand. Eye care
providers (including residents or students), or patients related to eye care providers were not
eligible to participate. Subjects who were enrolled in another clinical trial or subjects who
were pregnant also were not eligible. After the purpose of the study was explained to the
patients and a parent/guardian of minors, informed consent/ assent was obtained from the
patients and the parent/guardian of minors, as appropriate.
Subjects were asked to complete the CLAY CLRS and the CDC Healthy Days Core
Module survey.13–15 The CLRS tool was developed using patient-reported outcome
methods and is briefly described below.
Initial survey items were derived from a review of published known and presumed risk
factors for SCL-related complica- tions. Many items were deemed amenable to self-report,
but certain known risk factors which were thought to be difficult to accurately ascertain due to
poor patient recall or knowledge (e.g., accurate refractive error, diagnosis, or severity of
systemic disease) were not included. To elucidate other meaningful factors from clinical
findings, the CLAY study team conducted a review of records from a previous study.16,17
These items were used to create a bank of questions and response options. Questions
were refined to use only non- leading lay-language and to avoid double-barrel question
stems. Response options included: yes/no, Likert scales, and select one/mark all that apply.
The 5-point Likert scale used the labels ‘‘always,’’ ‘‘fairly often,’’ ‘‘sometimes,’’
‘‘infrequently,’’ and ‘‘never.’’ Readability of the questions and responses was assessed
at a fifth-grade level (average, 11 years of age), using Flesch-Kincaid statistics in Microsoft
Word software (Microsoft, Redmond, WA, USA). Photos were used to improve the
participant’s ability to identify their SCL and lens care products.18 Branching logic was
incorporated (i.e., patients who reported not using a lens case were not asked how often they
cleaned their lens case), and the survey was developed into an on-line (Web-based)
instrument using Qualtrics software (Qualtrics Labs, Inc., Provo, UT, USA) so that it could be
fielded with a desktop or portable computer.
Pilot testing of the CLRS was first conducted in healthy SCL wearers and was shown to
be able to discriminate among differences in patient behaviors, environmental exposures, and
health status by age.19 The survey was also assessed for within- subject repeatability, by
resurveying a group of 119 subjects 1 week after the initial survey. There was good
agreement between the test and retest responses for most items on the CLRS (see
Supplementary Appendix). Test–retest repeatability of contact lens care, hygiene, lens
dependence, environmentalexposure, and wellness were generally high, with most kappa values
(jw) above 0.61 (agreement was substantial or better). Eight items had only moderate
agreement (0.41–0.60), and none had less than moderate agreement. Most survey items also
showed high symmetry, indicating only random disagree- ment, if any. The test of symmetry
was below 0.5 for a few items. A nonrandom pattern to the observed disagreement occurred
for sleeping in contact lenses, number of colds/ influenza and stress level. It is reasonable to
expect that these responses could change over time. Data from healthy and red- eye SCL
wearers are being used to construct a scoring methodology for the CLRS tool for future use in
research or clinical care.
After subjects completed the CLRS, investigators conducted a scripted medical interview
with all case subjects and a health history with all subjects (cases and controls). The scripted
medical interview included questions regarding the CIE subject’s signs and symptoms,
attempts at self-treatment, and access to care. The health history queried current (the
previous week) SCL wear and care behaviors, as well as systemic and ocular health and
medication histories. A standardized biomicroscopy examination was conducted, and the
investigator cultured the ocular surface and contact lens and lens case for all CIE subjects
and one matched control subject for each CIE case. In this pilot study, cultures were
obtained only from the case subjects and one control subject per case due to costs
associated with the microbiological procures (see Culturing Methods below). Following
sample collection, sodium fluorescein (NaFl) was instilled to complete the anterior segment
evaluation. No further study-related procedures or visits occurred, and the subject was treated
and scheduled as was usual and customary for each site (see Supplementary Appendix for
scripted interview, health history, biomicroscopy and culture collection forms).

Culturing Methods
All study investigators were trained in proper culturing methods based on
previously reported techniques.20,21 Inves- tigators wore clean gloves and used separate
swabs and agar plates for each culture location. The lower eyelid margin and superior bulbar
conjunctiva of each eye were swabbed with a moistened calcium alginate swab and plated
onto chocolate agar (Fisher Scientific, Hampton, NH, USA). If the subject was wearing SCLs,
the lenses were aseptically removed from the eyes. If the SCLs were in lens storage
cases, lenses were aseptically removed from the case and the duration since lens removal
from the eye and type of lens care solution was recorded. Soft contact lenses were placed
in a vial with 1 mL nonpreserved sterile saline. Contact lens storage cases were kept and a
replacement case was provided to the subject.
Culture samples were maintained at 48C to 88C until they were shipped to the
central laboratory (University Hospitals Case Medical Center, Cleveland, OH, USA). If culture
samples were collected on Friday or Saturday, they were refrigerated and shipped Monday.
Culture samples were shipped overnight with cool packs to avoid overgrowth of organisms in
transit. All cultures were processed following previously described methods.20,21 Inoculated
plates were incubated in 5% CO2 for 48 h at 358C. All plates were read by masked
examiners after 48 h and reincubated and examined for up to 5 d if no growth was seen
initially. Upon arrival at the laboratory, contact lens specimens were aseptically removed
and placed concave side down on a chocolate agar plate, covered with 10 mL molten agar, and
incubated in 5% CO2 for up to 5 d at 358C. Storage cases were swabbed and plated on
chocolate agar plates as well. Colony-forming units (CFUs) were enumerated and colonies
identified by use of gram stain and standard identification methods.21 Based on previous
reports, ‘‘substan- tial microbial bioburden’’ was defined as ‡10 CFUs of any gram-negative
bacteria or higher virulence gram-positive organisms or high levels (‡80 CFUs) of normal
ocular biota (e.g., Corynebacterium, coagulase-negative staphylococci [CNS]).20–27
TABLE 1. Summary of CIE Cases

Manufac
Subje Severi Adjudica Visu Days No. turer
2 7 CLARE No None 4 1 Monthly SiHy MPS
3 1 CLARE No None 3 3 Daily Hydrog None
4 1 CLARE No None 1 2 Daily Unkno None
5 1 CLPU No None 6 3 2-wk SiHy MPS
6 2 CLPU No None 7 4 Monthly SiHy None
7 1 CLARE Yes None 5 3 2-wk SiHy H2O2
8 8 IK Yes None 8 2 2-wk SiHy MPS
9 1 IK No None 7 2 Monthly Hydrog MPS
10 1 CLARE Yes None 1 2 2-wk Unkno MPS
11 1 CLARE No None 9 2 Monthly SiHy H2O2
12 1 IK No None 8 2 2-wk SiHy Unkno
13 1 IK No None 9 3 Monthly SiHy MPS
14 1 CLARE Yes None 9 3 2-wk SiHy MPS
15 1 CLPU No None 1 5 2-wk SiHy MPS
16 2 CLPU No None 5 3 2-wk SiHy Unkno
17 1 CLPU No None 1 5 2-wk SiHy Unkno
18 1 CLARE Yes None 5 3 Monthly SiHy Unkno
19 1 CLPU No None 4 3 2-wk SiHy Unkno
20 1 CLPU No None 4 3 2-wk Hydrog MPS
21 1 CLPU No None 6 3 Daily Hydrog None
22 1 CLPU Yes None 1 4 2-wk SiHy MPS
23 1 IK No None 3 3 Monthly SiHy MPS
24 1 CLARE No None 5 2 Monthly SiHy None
25 1 IK No None 6 2 Monthly Hydrog MPS
 26 1 CLARE No None 7 2 2-wk SiHy MPS
27 1 IK No None 1 2 Monthly Hydrog MPS
28 1 CLARE No None 7 2 2-wk SiHy MPS
29 7 IK Yes None 5 2 2-wk Hydrog MPS
30 1 IK Yes Unknow 7 2 2-wk SiHy MPS
H2O2, hydrogen peroxide; MPS, multipurpose solution; SiHy, silicone hydrogel.
Adjudication of Cases
Subjects’ clinical records were used to adjudicate the cases to a final diagnosis
following previously described methods.16 Each CIE case was scored for severity using
Institute for Eye Research/L.V. Prasad Eye Institute Guide to Corneal Infiltrative Conditions
criteria.28,29 Scores were based on a 4-point scale for 10 items such that the final score could
range from 0 to 40, with 40 being the most severe.
Statistical Methods
Conditional logistic regression with univariate and multivariate modeling was used to
assess the effect of patient characteris- tics and behaviors as reported on the CLRS, scripted
medical interview, and health history data on the risk of CIE. This analysis methodology,
as opposed to simple logistic regression, was used due to the matching (3:1 ratio) of cases and
controls. Based on previous research indicating directionality of risk factors, a one-sided P
value and a 95% confidence interval upper limit are reported. Pilot data collected from
microbial culturing (1:1 matching) were used to explore trends between microbial bioburden
and behaviors or exposures using multiple logistic regression adjusted for confounding by
age and sex. These data were also used to determine ranges of sample sizes needed for a
full-scale study.

RESULTS
Sample Population (Cases and Controls)
Thirty CIE cases and 90 matched controls were enrolled between November
2013 and June 2014. Enrolled subjects were between 13 and 31 years of age (mean: 27.7
years of age), and 57% were female. There was a broad distribution of racial groups (37%
caucasian, 30% Asian, 16% Hispanic, 8% African American) represented in the study. The
majority of subjects were full-time (86% wore SCLs ‡4 d/wk) planned-replacement (46% 2-
weekly, 28% monthly) wearers. Most subjects wore lenses of silicone hydrogel (SiHy)
material (66% SiHy), and 79% used multipurpose solution (MPS) to clean and store their SCLs.
The type and severity of CIE cases are presented in Table 1. Most CIEs were located in
the peripheral or midperipheral cornea, were as deep as anterior stroma, and were 1.0 mm or
less in diameter. The average severity score was 13.5 6 3.5. Diagnoses of CIEs were almost
evenly distributed among contact lens-associated red eye (CLARE) with infiltrates (11
subjects), infiltrative keratitis (IK) (10 subjects), and contact lens peripheral ulcer (CLPU)
(9 subjects). The clinical treatment of CIEs varied somewhat by site and ranged from
temporary discontinuation of SCL wear to prescribing antibi- otic and/or steroid combination
drops. The median time to resolution was 7 days (mean 6 7.7 6 3.6 days), and required an
average of 3 office visits (2.7 6 0.9 visits). As expected, CIE cases were more likely to have
bulbar redness, papillae or follicles, conjunctival and corneal edema, discharge, corneal
scars, and corneal staining compared to controls (all P < 0.05).

TABLE 2. Univariate and Multivariate Models For Risk of Corneal Infiltrative Events From
Health History

Fact Response OR Upper 95% P aOR Upper 95% CI

3–6 mo – – 0.10 – – 0.24
Do not use a – – 0.22 – – 0.47
2 Refer Referen
Used ocular drops in the mo
N 3.53 ent
Referent 0.00 4.53 t
Referen 0.00
Cold/influenza in the last Ye 2.15 4.6 0.05 3.45 9.12 0.02
N Referent Referen
Overnight wear in the last Ye 3.35 6.8 0.00 3.30 7.76 0.01
N Referent Referen
Slept away from home in Ye 2.54 5.4 0.02
N Referent
aOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.
* Univariate, P 0.10; multivariate, P 0.05.
† P values in boldface indicate significance at the stated levels.
Scripted Medical Interview (Cases Only)

The scripted medical interview of CIE subjects indicated that the average onset of
symptoms occurred approximately 2.5 days prior to the appointment (2.44 6 3.46 days;
range, 2 hours to 14 days). The most common factors subjects reported for their delay in
seeking care were that they ‘‘thought it would improve on its own’’ or were ‘‘too busy.’’
Subjects reported typical symptoms of ocular redness, pain, burning, swelling, discharge,
and decrease in vision. The most common attempts to alleviate symptoms were to ‘‘rinse
and reinsert SCLs,’’
‘‘replace SCLs with a new pair,’’ or ‘‘use eye drops.’’

Health History and CLRS (Cases and Controls)

The ocular and systemic health history revealed that the majority of subjects
were not taking any oral medications beyond over the counter (OTC) vitamins and
supplements. A few subjects reported taking oral medications for birth control (13%) and
allergies (12%). The majority of subjects had medical insurance (65%), but less than half had
vision insurance (45%). Forty percent reported seasonal and/or environmental allergies.
There were five significant risk factors identified from the univariate analysis of the
health history data (Table 2). In the multivariate model (Table 2), subjects whose contact
lens storage case was six months of age or older, were nearly eight times more likely to have
had a CIE than those whose lens storage case was 2 months of age or newer (P ¼
0.01). Overnight wear, cold/influenza, and use of eye drops in the previous week were also
related to the risk of developing a CIE (all P 0.02). The ocular drops reported as being used
by CIE subjects were most often an OTC vasoconstrictor indicated to ‘‘get the red out’’ and
were likely associated with the subject’s attempt to self-treat prior to seeking professional help.
Scripted Medical Interview (Cases Only)

The scripted medical interview of CIE subjects indicated that the average onset of symptoms
occurred approximately 2.5 days prior to the appointment (2.44 6 3.46 days; range, 2 hours
to 14 days). The most common factors subjects reported for their delay in seeking care were that
they ‘‘thought it would improve on its own’’ or were ‘‘too busy.’’ Subjects reported typical
symptoms of ocular redness, pain, burning, swelling, discharge, and decrease in vision. The
most common attempts to alleviate symptoms were to ‘‘rinse and reinsert SCLs,’’
‘‘replace SCLs with a new pair,’’ or ‘‘use eye drops.’’

Health History and CLRS (Cases and Controls)

The ocular and systemic health history revealed that the majority of subjects
were not taking any oral medications beyond over the counter (OTC) vitamins and
supplements. A few subjects reported taking oral medications for birth control (13%) and
allergies (12%). The majority of subjects had medical insurance (65%), but less than half had
vision insurance (45%). Forty percent reported seasonal and/or environmental allergies.
There were five significant risk factors identified from the univariate analysis of the
health history data (Table 2). In the multivariate model (Table 2), subjects whose contact
lens storage case was six months of age or older, were nearly eight times more likely to have
had a CIE than those whose lens storage case was 2 months of age or newer (P ¼
0.01). Overnight wear, cold/influenza, and use of eye drops in the previous week were also
related to the risk of developing a CIE (all P 0.02). The ocular drops reported as being used
by CIE subjects were most often an OTC vasoconstrictor indicated to ‘‘get the red out’’ and
were likely associated with the subject’s attempt to self-treat prior to seeking professional help.
Univariate analysis of the CLRS data identified 10 significant risk factors for
developing a CIE (Table 3). In the multivariate model (Table 3), subjects who reported a
previous red eye event, used MPS, slept overnight in their SCLs ‘‘always’’ or ‘‘fairly
often,’’ or who replaced their SCLs less often than daily were 3 to 10 times more likely to have
experienced a CIE. As mentioned previously, biomicroscopy data indicated that CIE subjects
were more likely to have a pre-existing corneal scar, which supports the patient-reported
CLRS finding of previous red eye events. The remainder of the CLRS questions, including
living environment, hand-washing behaviors, stress, and health status were not significant in
this pilot study (all P > 0.05). Although not significantly related to risk of CIE, it was also
noted from the CLRS tool that nearly half (43%) of subjects reported rinsing and/or storing
their SCLs in water at least infrequently; a behavior that is associated with the risk of
acanthamoeba keratitis, one of the most severe forms of microbial keratitis (MK).30,31
None of the CDC Healthy Days Questions were significantly associated with the risk of
developing a CIE (all P > 0.05, data not shown).
 A multivariate model with data from both the CLRS and health history was
explored to determine which information best predicted the risk of a CIE (Table 4). This final
model included two factors from the health history (recent illness and self-treatment prior to the
event), and four from the CLRS (overnight wear, previous red eye, use of MPS and rinsing SCLs
with water) all of which were more likely to be associated with development of a CIE.

Microbial Cultures
Eyelid and conjunctival cultures were obtained from almost all the CIE cases and
controls (Table 5). One subject declined bulbar conjunctival swabs due to discomfort. Many
of the CIE subjects discarded their SCL at the onset of the event, so there were fewer SCL
available for culturing from CIE subjects (17 of 30) compared to control subjects (27 of 30).
Fewer than half of all subjects presented to the visit with their lens storage cases.
Corneal infiltrative event subjects were more likely to have substantial levels of
bioburden on their eyelids, conjunctivas, and contact lenses (Table 5, all P 0.02). The type of
bacteria was generally consistent across the eyelid margin, conjunctiva, contact lenses, and
storage case, where available (Table 6). Culture-positive CIE subjects harbored mostly
gram-negative bacteria. The bacteria identified on the healthy control subjects were primarily
normal commensal flora and did not reach the threshold of substantial levels of bioburden for
most subjects; however two control subjects had substantial levels of CNS and one subject
presented with Escherichia coli in their lens storage case.

TABLE 3. Univariate and Multivariate Models For Risk of Corneal Infiltrative Events From
the CLRS

Daily Referen Referen

Overnight wear of SCL Always/fairly 6.46 19.06 0.002 4.84 15.88 0.02
Sometimes 2.58 7.5 0.075 – – 0.16
Infrequently/n Referen Referen
Lens care product MPS 3.80 13.76 0.044 4.62 18.26 0.03
Hydrogen Referen Referen
Previous red eye event Yes 2.55 5.1 0.014 3.27 7.84 0.01
No Referen Referen
ECP recommends Yes 18.00 106.40 0.004
No Referen
Showering in SCL Always/fairly 3.16 8.3 0.026
Sometimes – – 0.20
Infrequently/n Referen
>18 h of SCL wear/d Always/fairly 3.07 7.0 0.014
Sometimes – – 0.68
Infrequently/n Referen
Smoking Yes 3.00 8.9 0.050
No Referen
Rinse SCL with tap Yes 2.39 5.0 0.026
No Referen
Other exposure of SCL Yes 2.13 4.7 0.063
No Referen
ECP, eye care practitioner.
* Univariate, P 0.10; multivariate, P 0.05.
 Exploratory logistic regression analyses were conducted to determine if certain
CLRS questions were associated with substantial levels of microbial bioburden. To avoid
type II errors, only questions previously shown to be related to microbial bioburden or that
were strongly biologically plausible were tested. The questions selected were overnight SCL
wear, rinsing/ storing SCLs in water, washing hands before inserting/removing SCLs, topping
off contact lens solution, and use of and frequency of replacement of lens storage case. Due to
the limited microbial cultures of SCLs and lens storage cases, only the culture result from the
lid margin was used as the outcome variable. After adjusting for age and sex, none of the
selected predictor variables were associated with substantial levels of microbial bioburden on the
eyelid margin (all P > 0.05). Sample size calculations using the microbial culture and CLRS
data assumed an expected odds ratio of 2 to 3 using a logistic regression to predict lid burden
with a single categorical predictor. If 50% of outcome response is positive (i.e., 50% of
participants experience significant bio- burden), 50% R2 between the main predictor and
other predictor, and 50% at baseline have a positive outcome, we would need between
230 and 544 persons (total case and control subjects) to achieve at least 80% study power.

TABLE 4. Multivariate Model For Risk of Corneal Infiltrative Events Using Health History
and CLRS Data
Source of Fact Respo aO Upper 95% P

Hydrogen Referent
Health history Ocular drops in last Yes 7.72 24.8 <0.
No Referent
CLRS Overnight wear of Always/fairly 5.45 21.4 0.0
Sometimes – – 0.2
Infrequently/neve Referent
CLRS Previous red eye Yes 4.16 13.4 0.0
No Referent
Health history Cold/influenza in last Yes 3.41 9.6 0.0
No Referent
CLRS Rinse CLs with tap ‡Infrequently 2.85 8.1 0.0
Never Referent
* P values in boldface indicate P 0.05 level.
TABLE 5. Cultures With Substantial Levels of Bioburden and Total Cultures Obtained For
Cases and Controls

location Cases with significant controls with significant P value

bioburden/total cultured bioburden/total cultured (%)
(%)

Bulbar conjunctiva 5/30 (16.7) 0/29 0.02

Contact lenses 6/17 (35.3) 0/27 <0.0
Lens storage case* 5/10 (50.0) 2/14 (14.3) 0.058
Chi-square tests were used for the proportion of substantial bioburden between cases and
controls.
* Three case and 6 control subjects reported not using a lens storage case.
† P values in boldface indicate P 0.05 level.

DISCUSSION
The sample enrolled in the CLAY ORACL study was a good representation of the
current SCL-wearing population in the United States as the majority of subjects were full-time
wearers using silicone hydrogel planned replacement SCLs and multipurpose care solutions.2
The type and severity of CIEs were also representative of the typical ‘‘red eye’’ patient seen
in general optometry or ophthalmology practice (i.e., not at a corneal specialist or tertiary
referral site). The average event lasted approximately one week and required three doctor
visits which supports the CDC’s report that, although ‘‘mild to moderate’’ CIEs may not
cause permanent visual loss, they can result in meaningful personal and financial burden.1
The scripted medical history revealed that subjects who experienced a CIE were more
likely to have had an illness in the week prior to the event. Poor or compromised health has
been established as a risk factor for CL-related complica- tions.32,33 These subjects
were also more likely to have slept away from home prior to the event, which is a new finding
and could be associated with patients not having their typical lens care products with them and
thus over wearing lenses or using different lens care products.
A number of known and novel risk factors for developing a CIE were identified in
the self-reported CLRS data. Not surprisingly, subjects with active infiltrative events were
more likely to have slept overnight in their SCLs.5,17,32,34–38 CIE case subjects had increased
exposure to soiled contact lenses; both by extending their SCL daytime wearing hours and
extending the replacement of their SCLs. Our and others’ work has demonstrated that
planned replacement SCLs are associated with higher risk of complications than daily
disposable lenses,16,17,39,40 but little has been reported regarding the effects of longer
SCL wear hours. It could be hypothesized that the longer wear hours further compromise the
ocular surface and allow adherence and colonization of bacteria and thus increase the
likelihood of a CIE. Other established risk factors supported by this study were use of an
older contact lens storage case,41,42 and use of multipurpose solutions (versus hydrogen
peroxide),17,39,43 and smoking.32,37,44–47
Surprisingly, most subjects (both cases and controls) reported showering
while wearing their lenses and/or exposing their lenses to other water sources (e.g.,
pools and hot tubs), and CIE cases in this study were significantly more likely to report
rinsing their SCLs in tap water. Exposure of SCLs or lens storage cases to water is a
well- established risk factor for the development of microbial keratitis, especially visually
threatening Acanthamoeba keratitis.31,42,48 Water exposure has also been associated with
contamination of contact lenses with pathogenic gram- negative bacteria.27
In the multivariate analysis of the CLRS with the scripted history, most of the
factors that remained significant were consistent with those previously reported in the literature
(overnight wear of SCLs,4,5,17,19,34,37,49 previous CL complica- tion,45 use of
multipurpose solution,17,43,48,50 SCL exposure to water,30,31,42,48 and illness33). Some
factors that dropped out of the multivariate analysis were closely linked with other factors (i.e.,
wearing SCLs greater than 18 h/d was highly associated with overnight wear).
Previous CLAY Study Group results have shown that there are significant
differences in behaviors and environmental exposures by age.51–53 Due to age matching and
the relatively small sample in this study, it was not possible to examine differences in
risks by age. Further research is warranted to examine the influence and interactions of the
multiple known and presumed risk factors in younger and older populations of SCL wearers.
This study was also designed to pilot multisite collection and central processing of
microbial cultures of clinical patients. A total of 14 of the 30 CIE subjects were shown to
harbor substantial levels of bioburden on their ocular surface, contact lens, or lens case. It is a
known limitation of standard culturing techniques that only ‘‘viable’’ bacteria can be detected
even though dead bacteria, endotoxins, and exotoxins are able to trigger inflammatory events.
There are also many bacteria that simply do not grow under standard laboratory conditions. It
is therefore not surprising that some CIE subjects had low levels of detectable
contamination.22,54 As shown by other groups, significant levels of gram-negative bacteria
were more common in subjects with active CIEs compared to healthy con- trols.21,22,24,54
It is noteworthy that, while culturing is not the standard of care for CIEs considered to be
low risk for MK, this study revealed that even mild to moderate case presenta- tions harbored
gram-negative bacteria known to be resistant to standard treatment regimens (e.g.,
Achromobacter xylosox- idans and Elizabethkingia and Delftia spp).21,55 Consistent with
previous findings, the bacteria identified on the majority of the healthy control subjects were
normal commensal flora below our specified levels of substantial bioburden.21,22,27 The
control subject who showed substantial bioburden on the lens storage case but did not have an
active CIE at the time of the study, could have been at risk of developing one in the future had
he continued to use the same soiled lens storage case. One of the limitations of a cross-sectional
study is that it is only a snapshot in time and cannot fully describe the subjects’
exposures and risks.
There were some additional limitations to this study. There were fewer SCLs and
lens storage cases available for culture than had been planned. The sites did their best to
educate potential CIE and Control subjects to bring their SCLs and lens storage case to their
appointments, but it was not realistic to expect that all patients would follow these
instructions. Based on this and the aforementioned limitations of standard culturing
techniques, future studies should enroll larger samples to allow for missing culture data or
should consider other types of microbial assessment (i.e., RNA based analy- sis).55,56
Because our study and those of others have shown that the bulbar conjunctiva generally
harbors the same or fewer microbiota, future studies could consider forgoing conjunctival
culturing to save costs and minimize time.20,27 The relatively small sample of positive
culture results limited the ability to assess relationship between CLRS patient- reported
behaviors and exposures and microbial bioburden. And, while the study group has been
making steps toward a broader assessment of the many known and presumed risk factors,
the ORACL pilot study did not assess all of the known and presumed drivers of CL
complications (i.e., genetic predisposition, ocular immune response).57–59 Nevertheless, this
study demonstrated that the use of standardized patient surveys and study procedures allowed
systematic collection of detailed data that would not otherwise have been available from
clinical records and can be used as a model for future studies.51,52,60

CONCLUSIONS
This pilot study demonstrated feasibility of enrolling a diverse and representative mix
of active CIE and control subjects, and assessment of risk factors using a multipronged
approach that included a self-administered patient survey, trained investigator examination, and
microbial culturing. A larger study is needed to better understand relationships between
microbial biobur- den and behaviors and exposures of SCL wearers.